Developing joint health and wellbeing board arrangements:

Cambridgeshire and Peterborough

Summary

- In the process of establishing a formal joint health and wellbeing board (HWB) sub-committee with delegated authority.
- Delivered interim joint arrangements while constitutional issues were worked out; produced a joint JSNA core data set and have agreed to develop a shared health and wellbeing strategy.
- A peer challenge of the health and care system resulted in important recommendations for system improvement.

Overview

Cambridgeshire County Council is in the East of England; it has five district councils and an estimated population of 647,238. Peterborough City Council is a unitary council with a population of around 193,000 and lies within the geographical area of the county.

Councils in Cambridgeshire and Peterborough have formed a combined authority with an elected mayor, working with the local enterprise partnership on transport infrastructure and affordable housing. Cambridge and Peterborough councils also work closely together on many aspects of health, wellbeing and social care. They have a joint chief executive, executive director of adult and children’s services, and director of public health. Although Cambridgeshire and Peterborough have different populations and geographies, and a strong sense of local identity, there are also many commonalities.

The councils are coterminous with Cambridgeshire and Peterborough CCG and Cambridgeshire and Peterborough STP. The shared boundary and willingness to work together means that the councils and the CCG have established a strong partnership to develop system-wide integration where it makes sense to do so. Councillors and senior officers are members of the STP Board, which has begun to meet in public. Senior council officers are members of the STP’s Health and Care Executive and actively contribute to, and lead some, STP delivery groups. The STP, which will develop into an integrated care system (ICS), reports regularly into the HWBs.

The STP has developed two partnership groups – ‘North and South Alliance Delivery Groups’ which have representation from health and social care commissioners, providers, patients and the voluntary, community and social enterprise sector (VCSE). There are also four Living Well Partnerships: East Cambridgeshire and Fenland, Huntingdonshire, South Cambridgeshire and City and Peterborough. The aim is to develop an integrated neighbourhood model across populations of 30,000 to 60,000 people – currently being piloted in two areas in Cambridgeshire. All community-based services will deliver preventative and holistic care that enable people to live healthier for longer and more independently.

Developing a joint health and wellbeing board

Councillors’ Perspective

Our interim joint HWB arrangements have been working well and we look forward to a formal joint board being established. The joint HWB provides a strategic approach across the whole of Cambridgeshire and Peterborough, taking into account areas of need, local priorities and health inequalities.

With the development of a Cambridgeshire and Peterborough JSNA core data set and the consideration of a system-wide joint health and wellbeing strategy, there is much the joint board can do to take a more active role in overseeing commissioning of integrated health and care and wellbeing. A key task will be to deliver the joint Health and Social Care System Action Plan, agreed following an LGA peer review last year.

It is important that health and wellbeing boards are meaningful, and that members can see how they are making a difference through establishing systems to monitor progress. HWBs need to focus on key strategic issues, engage well with clinicians and make sure that they are able to take decisions effectively.

Councillor John Holdich OBE, Leader, Peterborough Council; Deputy Mayor Cambridgeshire and Peterborough Combined Authority; joint Chair Cambridgeshire and Peterborough joint Health and Wellbeing Board

Councillor Roger Hickford, Deputy Leader, Cambridgeshire County Council; joint Chair Cambridgeshire and Peterborough joint Health and Wellbeing Board

Joint development session

With the development of integration across the STP, chairs and members of the HWBs recognised that it would be helpful to consider system-wide issues together. They commissioned the LGA to undertake a joint development session in January 2018 as part of its HWB and system leadership support programme. The aim was for both HWBs to better understand accountabilities, the work of individual boards, shared priorities and future ways of working.

The session was facilitated by an LGA associate experienced in supporting health and care integration. Participants considered information from the JSNA core data sets and health and wellbeing strategies. They identified and explored the following key themes for future joint working: • integrated solutions (not just integrated services) and the collective impact of a joint HWB • a focus on place-based integration and commonality of need • prevention – working through outcomes and priorities, including health inequalities, mental health and early years • population growth, including new communities, healthy new developments and impact of demand and resources.

Councillor Perspective

Developing a joint health and wellbeing board across Cambridgeshire and Peterborough has brought many benefits. As councillors and leaders of place, we can develop a shared view about our joint priorities. Cambridgeshire is a varied county – some areas are rural, some very affluent, some deprived – and some areas of Cambridgeshire have similar local needs and priorities to Peterborough. This means it makes sense to take a joined-up approach. There are also opportunities for us to learn from each other about what is working well in our areas and change what we do. This is energising the work of the joint HWB.

Discussing system-wide issues with key people in a single forum is very helpful. For example, the chief executive of the largest hospital trust attends the interim joint board, so discussions can take place about issues across both areas. Also, in practical terms, a joint HWB makes sense to avoid duplication and so that people are clear about where to raise issues. Health and wellbeing boards are statutory arrangements and have an important role in overseeing health, care and wellbeing reform.

Councillor Peter Topping, Cambridgeshire County Council, Joint Chair Cambridgeshire and Peterborough interim joint HWB, 2018

Establishing the joint HWB

Following the development session, work took place to formalise joint working by establishing a joint HWB. This was welcomed by officers reporting to the HWBs on system-wide issues, since it meant far less duplication of reporting. A paper was submitted to each HWB in April 2018. Peterborough HWB accepted the paper and subsequently the City Council agreed to a change in terms of reference to allow a sub-committee of the HWB in relation to issues that cross local authority boundaries. Cambridgeshire HWB, which has a large membership including district council members, requested more information on proposals for the membership of the sub-committee.

It was agreed that in the intervening period interim arrangements for the two HWBs to meet together would take place (described below).

Following agreement at Cambridgeshire HWB in November 2018, Cambridgeshire County Council’s Constitution and Ethics Committee reviewed the proposal to establish a joint Cambridgeshire and Peterborough HWB as a sub-committee of Cambridgeshire HWB and Peterborough HWB for items that are relevant to both committees, such as wider system integration. The joint board would be able to discharge agreed functions of both boards and would have delegated decision-making authority. Membership would comprise the full membership of both HWBs. Terms and reference and chairing arrangements would need to be agreed by both HWBs. The proposal was agreed by Cambridgeshire Council in December 2018.

Individual HWBs will continue to meet to consider health and wellbeing priorities of their areas at a frequency that they determine. They will oversee the agenda for the HWB so it is focused on system-wide issues.

**Interim shared arrangements – 2018**

Two meetings of both HWBs with a shared agenda took place in 2018 – in May and September. The chair of the meeting was rotated, and any decisions were taken separately by each board, led by the two chairs.

The joint meetings considered priority system-wide issues, including STP public engagement, the dementia strategic plan and the footprints of local arrangements such as the four Living Well Partnerships across Cambridgeshire and Peterborough. They also agreed several measures that would support future joint working:

- establishing a Cambridgeshire and Peterborough JSNA core dataset so that data for the STP footprint appears together
- scoping the feasibility of a Cambridgeshire and Peterborough joint health and wellbeing strategy
- further work to establish a joint HWB
- inviting the LGA to conduct a peer review of the local health and care system in preparation for a future CQC system-wide review.

**CCG perspective**

With an STP aligned over a single CCG and two local authorities it makes sense to have a joint HWB as a forum for single conversations about system-wide health developments, rather than taking the same issue to two boards.

It is also helpful to work together to understand the whole population of Cambridgeshire and Peterborough, and the sub-groups within this – there are significant differences in geographies and levels of affluence and deprivation in the area. This means we can tackle big system challenges as well as focusing on specific local issues.

We are working to set up one ICS with two delivery alliances – in the North and South. We are also establishing primary care networks that will largely fit with local authority community and neighbourhood approaches.

In the coming months we will be looking together at how the ICS and the joint HWB can best collaborate without duplication. The joint HWB is likely to have a role in oversight of how commissioning plans align across the ICS footprint and how resources are distributed. Also, in looking at how a strategic approach to prevention can be further developed – perhaps involving the Police and Crime Commissioner, for instance.

The joint HWB started with a joint workshop and we plan to have another in a few months to consider strategic leadership, at this exciting time.

**Dr Gary Howsam, Clinical Chair, Cambridgeshire and Peterborough CCG** CCG perspective

The joint HWB brings together key partners responsible for health and wellbeing in the Cambridgeshire and Peterborough footprint – CCG, STP, community mental health provider and two councils – which means we can have joined-up conversations about shared priorities and action.

The joint board is agreeing a core JSNA dataset which will give us a better overview of the different demographics of the area combining high level strategic population health data with information about localities. We have also recently agreed to create a joint health and wellbeing strategy across Cambridgeshire and Peterborough.

Having moved from an area with multiple organisations in the STP footprint, it is very helpful to be able to work in this coterminous way. I feel really positive that we have a massive opportunity to move forward together at pace and scale.

Jan Thomas, Chief Officer Cambridgeshire and Peterborough CCG

LGA peer review of health and care system-wide support for older people

In September 2018, the LGA delivered a three-day peer review based on CQC system-wide review inspection methodology, involving the councils, the CCG, NHS providers, Local Healthwatch and the VCSE sector. The review included a document review and onsite visits. Two overarching questions were asked supported by more detailed key lines of enquiry (KLOEs). The questions were:

- Is there a shared vision and system-wide strategy developed and agreed by system leaders, understood by the workforce and co-produced with people who use services?
- People’s journey – how does the system practically deliver support to people to stay at home, support them in crisis and help to get them back home?

The peer review concluded that “all the right ingredients” were in place to move forward and that there was good energy and commitment at all levels of partner organisations, from executive leaders to front line staff and wider stakeholders. There were also some excellent services and approaches to prevention, supporting independence and avoiding hospital admission. However, these were not always consistent and when people were admitted to hospital there were problems in discharging them.

The review made specific recommendations which will have a major impact on how services are integrated. These include:

- Produce a single vision that is person focused and co-produced with people and stakeholders.
- Ensure that strategic partnerships include primary care, the voluntary sector and social care providers.
- Establish Homefirst as a default position for the whole system.
- Simplify processes and pathways to make it easier for staff to do the right thing.
- Homecare – work with providers to review current arrangements and produce new ideas and solutions.
- Work to put primary care centre stage. • Understand the collective pound and agree whether resources are in the right place ahead of winter and in the longer term. • Develop a cross-system organisational development programme that reflects the whole system vision and supports new ways of working.

Cambridgeshire and Peterborough partners have produced an action plan to address the recommendations. The joint HWB will have a key role in monitoring the system’s progress in terms of implementing the plan.

**STP perspective**

The central team for Cambridgeshire and Peterborough STP is not a member of the joint HWB but attends meetings for specific items, and all the system partners are members. Furthermore, councillors from both areas are members of the STP Board.

My view is that the joint HWB has proved very useful because of the significant overlap and similarity in priorities between the health and well-being and system transformation agendas. All partners are seeking to tackle health inequalities and take a strategic approach to prevention – for example, looking at new housing developments, education and the wider determinants of health. This fits with the greater emphasis on prevention in the NHS Long Term Plan – such as the best start in life for children.

In future I would hope to see further developments such as discussions on: how the Better Care Funds can be used strategically across wider system priorities; the potential benefits from more integrated health and social care commissioning; and how best to use resources across the system. Also, as the STP transitions into an ICS, we will need to clarify the relationship with the HWB and make sure there is a joined-up approach, without duplication, going forward.

*Catherine Pollard, Executive Programme Director, Cambridgeshire and Peterborough STP Delivery Unit*

**Challenges, benefits and the future**

Establishing a joint HWB from a unitary and a county HWB which have different memberships and approaches has required discussion and negotiation over time. As Cambridgeshire and Peterborough chose the option of delegated authority to the joint board, this had constitutional implications which had to be agreed by the full council of both authorities. For Cambridgeshire, it also had to be considered by the Constitutional and Ethics Committee. The partners are now in the final stage of agreeing terms of reference for the joint sub-committee.

One of the advantages of taking time has been the opportunity to identify what could be done to improve how the joint board operates, such as greater involvement of the VCSE sector. The joint HWB is seen as having greater impact and influence because it operates across the whole health, care and wellbeing system.

Interim arrangements have allowed both HWBs to operate together and to start some major pieces of joint work, such as the core JSNA data set and joint health and wellbeing strategy. These will allow the system to build system-wide intelligence while also being able to drill down into the needs of local areas to inform an overarching strategic approach. The recommendations from the peer review of system-wide provision are influencing how local partners shape integration delivery. The joint HWB has also supported other peer review activity where this has implications across the system. This includes the forthcoming reviews of public health, and early years and social mobility.

These developments form a solid foundation for system-wide collaboration into the future. Developmental sessions have proved very useful for deepening collaboration, and a further session is planned to consider system leadership in the developing integration landscape outlined in the NHS long-term plan.

Key messages

- The LGA developmental session was very helpful for encouraging open discussion and provided hard data which showed the advantages and benefits of a joint board.
- Joint meetings under interim arrangements proved successful and it is likely that the combined expertise and perspectives of the new joint board will provide renewed energy for shared approaches.
- Establishing new relationships and joint ways of working is likely to take time, but this is needed to make sure everyone is on the same page when they go forward together.
- As well as the benefits of a joint board, it is important for individual HWBs to maintain a focus on their sense of place and local priorities.
- Democratic Services have been extremely helpful in developing and supporting the joint board and are a key factor for success.

Contacts

Helen Gregg, Partnership Manager Peterborough Council/Cambridgeshire Council Email: Helen.gregg@peterborough.gov.uk

Kate Parker, Head of Health Business Programmes, Cambridgeshire County Council Email: Kate.Parker@cambridgeshire.gov.uk

Links

Cambridgeshire and Peterborough STP https://www.fitforfuture.org.uk/

Cambridgeshire Health and Wellbeing Board https://cmis.cambridgeshire.gov.uk/ccc_live/Committees/tabid/62/ctl/ViewCMIS_CommitteeDetails/mid/381/id/12/Default.aspx

Peterborough Health and Wellbeing Board https://democracy.peterborough.gov.uk/ieListMeetings.aspx?CId=526&Year=0